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The Comparison of Buttock Pain, Defecation And Urination Symptom In

Prolapse Patients With Sacrospinosus Fixation And Without Sacrospinosus


Fixation In RSMH Palembang 2014

By
Amir Fauzi MD
Supervisor
Prof. DatoDrAsbi bin Ali

A THESIS PROPOSAL
SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR
THE DEGREE OF Ph. D

AT
MANAGEMENT AND SCIENCE UNIVERSITY
2015

LIST OF CONTENT

TITLE PAGE.......................................................................................................... i
LIST OF CONTENT.............................................................................................. ii
LIST OF TABLE.................................................................................................... iii
CHAPTER I INTRODUCTION........................................................................... 1
1.1................................................................................................................Bac
kground ................................................................................................ 1
1.2................................................................................................................Sco
pe of Research ...................................................................................... 2
1.3................................................................................................................Pro
blem Identification ............................................................................... 2
1.4................................................................................................................Aim
of Study ................................................................................................ 2
1.5................................................................................................................Ben
efit of Study .......................................................................................... 2
1.6................................................................................................................Hip
othesis................................................................................................... 2
CHAPTER II LITERATURE REVIEW ............................................................. 3
2.1. Pelvic Organ Prolapse ............................................................................3
2.1.1. Definition ..................................................................................... 3
2.1.2. Prevalence ................................................................................... 3
2.1.3. Etiology ....................................................................................... 3
2.1.4. Symptom ..................................................................................... 4
2.1.5. Patophysiology............................................................................. 5
2.1.6. Grading ........................................................................................ 6
2.1.7. Imaging ........................................................................................ 6
2.1.8. Differential Diagnosis ................................................................. 7
2.1.9. Treatment ..................................................................................... 7
2.1.10. Surgery ...................................................................................... 9
2.1.11. Prevetion..................................................................................... 11
2.2. Sacrospinous Fixation ............................................................................ 11

2.2.1. Definition ..................................................................................... 12


2.2.2. Aim .............................................................................................. 12
2.2.3. Indication ..................................................................................... 12
2.2.4. Contraindication .......................................................................... 12
2.2.5. Procedure ..................................................................................... 13
2.2.6. Complication ............................................................................... 16
2.2.7. Recovery ...................................................................................... 18
CHAPTER III RESEARCH METHOD ............................................................. 19
3.1. Research Design ..................................................................................... 19
3.2. Place and Time ....................................................................................... 19
3.3. Population and Sample .......................................................................... 19
3.4. Variable .................................................................................................. 19
3.5. Data Collecting ...................................................................................... 20
3.6. Data Analysis ......................................................................................... 20
3.7. Reseach Plan .......................................................................................... 21
3.8. Research Budget .................................................................................... 21
REFERENCES ...................................................................................................... 23

LIST OF TABLE

Table
Page
1.1 Research Plan ........................................................................................... 26
1.2 Research Budget ....................................................................................... 27

CHAPTER I
INTRODUCTION
1.1. Background
Pelvic organ prolapse is a common health problem affecting up to 40% women over
50 years old. It is defined as the descent of one or more of the pelvic organs. Anterior
vaginal wall prolapse concerns the bladder ancLor urethra (cystocele, urethrocele).
Apical prolapse entails either the uterus or post-hysterectomy vaginal cuff. Posterior
vaginal wall prolapse concerns the rectum but can also include the small or large
bowel (rectocele, enterocele). Women can present with prolapse of one or more
compartments.1
The life-time risk for women to undergo surgery for the management of POP
is about 11% and approximately 30% of these women will need additional surgery
because of prolapse recurrence.21n the US, the estimated lifetime risk of an 80-yearold woman undergoing surgical treatment for prolapse or urinary incontinence is
about l0%.3There are 43 cases of uterine prolapse in RSMH Palembang from 19992003.4The risk of uterovaginal prolapse increases with the number of vaginal births
and is higher in older and obese women.5The risk of prolapse repair after
hysterectomy was 4.7 times higher in women whose initial hysterectomy was
indicated for pelvic rgan prolapse and 8 times higher if preoperative prolapse grade 2
or more was present.6
Surgical procedures for treatment of vaginal vault prolapse are generally
categorized as either obliterative or reconstructive, and can performed either
abdominally or vaginally.7 More than 40 different operations have been described,
and all reconstructive techniques have in common the use of healthy structures for
cranial fixation of the vaginal vault.81n the last decades, many studies showed that
sacrospinous ligament fixation is an effective surgical procedure to correct
posthysterectomy vaginal vault prolapse.9Sacrospinous fixation was first described by
Sederl in 1958, and later popularized in Europe by Ritcher and Albright and in the
USby Randall and Nichols. 10Sacrospinouscolpopexy suspends the vaginal vault
towards the sacrospinous ligament, repositioning the upper vagina over the levator
plate. This procedure has been described in women who wanted to preserve the uterus
to retain fertility. 12Sacrospinoushysteropexy is anatomical efficient and safe and
most women are highly satisfied about the procedure.3The procedure can also be
used as an adjuvant technique to vaginal hysterectomy and anterior/posterior repair
for marked uterovaginal prolapse in the presence of poor cardinal and uterosacral
ligaments. One advantage of sacrospinous fixation is the possibility of concomitant
surgical repair of other vaginal defects.4,5
POP is associated with a few serious complications.It has significant negative
effects on a womans quality of life, ranging from physical discomfort, psychological
and sexual complaints to occupational and social limitations. It has been suggested
that hysterectomy may cause nerve supply damage and disrupt supportive structures
of the pelvic floor. Therefore women may be at increased risk for bladder dysfunction
and new-onset stress incontinence after vaginal hysterectomy. Buttock pain on the
side where the sacrospinous sutures have been passed occurs in approximately 1015% of the women but typically resolves in days to months.6,8
The anatomical outcome and complication rate of this operation was
described in few reports, but ncost authors do not focus on urogenital symptoms and
quality of life after sacrospinoushysteropexy.It was just mainly assessed in terms of
anatomical results)So, although anatomical outcome of the sacrospinoushysteropexy
appears to be good, we cannot conclude from current literature that this type of

surgery is associated with a significant functional improvement of urogenital and


defecatory symptoms.25The mean follow-up of other studies were also relatively
short, which just contain the post operative anatomical status from the medical
records, and not assessed the differences in urogenital symptoms in relation to the
anatomical outcome.
In this study, we set out to assess the satisfaction, complications such as
urogenital symptoms and defecation symptoms, and also quality of life in a group of
women after a sacrospinoushysteropexy comparing to those who didnt had the
sacrospinous fixation (normal transvaginal hysterectomy) in RSMH Palembang. ThIs
study
will
evaluate
unusual
complications
following
transvaginalsacrospinouscolpopexy for treatment of vaginal vault prolapse and find
the outcome differences with normal transvaginal hysterectomy.
1.2. Scope of Research
This study is limited to an attempt to overcome differences defecation urination
disorders and pain in patients after prolapse surgery with or without sacrospinous
ligament fixation. This study does not address the long form of the vaginal
anatomical outcome and recurrence.
1.3. Problem Identification
1.3.1. How is the comparison between urinary complication in prolapse surgery with
sacrospinous fixation and without sacrospinousfixation
1.3.2. How is the comparison between defecation complication In prolapse surgery
with sacrospinous fixation and without sacrospinous fixation
1.3.3. How is the comparison between buttock pain in prolapse surgery with
sacrospinous fixation and without sacrospinousfixation
1.4. Research Aim
1.4.1. To know the comparison between urinary complication in prolapse surgery
with sacrospinous fixation and without sacrospinous fixation
1.4.2. To know the comparison between defecation complication in prolapse surgery
with sacrospinous fixation and without sacrospinousfixatIon
1.4.3. To know the comparison between buttock pain in prolapse surgery with
sacrospinous fixation and without sacrospinous fixation
1.5. Research Advantages
We can know which better between sugery with sacrosplnousfixatIon or without
sacrospinous fixation, in term urinary, defecation, and buttock pain symptomafter
surgery. Uroginecologist can consider what surgery is better to perform, so it can
increase patient satisfaction and quality of life after surgery.
1.6. Hypothesis
There was no significant differences between urinary, defecation, and buttock pain
symptom between patient with sacrospinous fixation and without sacrospinous
fixation.

in the support of the pelvic oor. The etiology of the fascial or ligament defects
that leads to prolapse is multifactorial.29

Etiology for pelvic organ prolapse include the following:


l. Congenital
Two per cent of symptomatic prolapse occurs in nulliparous women. implying
that there may be a congenital weakness of connective tissue. In addition, genital
prolapse is rare in Afro-Caribbean women, suggesting that genetic differences exist.
2. Childbirth and raised intra-abdominal pressure
The single major factor leading to the development of genital prolapse appears
to be vaginal delivery. Studies of the levatorani and fascia have shown evidence of
nerve and mechanical damage in women with prolapse, compared to those without,
occurring as a result of vaginal delivery. Parity is associated with increasing prolapse.
The World Health Organization (WHO) Population Report (1984) suggested that
prolapse was up to seven times more common in women who had more than seven
children compared to those who had one. Prolapse occurring during pregnancy is
rare, but is thought to be mediated by the effects of progesterone and relaxin. In
addition, the increase in intra-abdominal pressure will put an added strain on the
pelvic oor and a raised intra-abdominal pressure outside pregnancy (e.g. chronic
cough or constipation) is also a risk factor.
3. Ageing
The process of ageing can result in loss of collagen and weakness of fascia and
connective tissue. These effects are noted particularly during the post-menopause as a
consequence of oestrogen deciency.
4. Postoperative
Poor attention to vaginal vault support at the time of hysterectomy leads to
vault prolapse in approximetaly 1 per cent ofcases. Mechanical displacement as a
surgery, such as colposuspension, may lead to the rectocele or enterocele.
Others risk factor that can cause prolapse include increasing body massindex
(obesity), the number of vaginal delivery, macrosomic delivery, chronic obstructive
pulmonary disease. constipation, strenuous activity. Weight bearing.Or strenuous
labor.and in hispanic race.30,31
II.1.4. Symptom
Symptoms of pelvic organ prolapse have been dened by International
Urogynecological Association and International Continence Society as a departure
from normal sensation. structure, or function, experienced by the women in reference
to the position of her pelvic organs.29

In severe prolapse, the woman can see or feel a bulge of tissue at or past the
vaginal opening. Most women have mild prolapse-the organs drop down only
slightly and do not protrude from the opening of the vaginaand do not have any
signs or symptoms. Some women with mild prolapse and women with severe
prolapse do have symptoms, which can include the following:27

Feeling of fullness or heaviness in the pelvic region


Pulling or aching feeling in the lower abdomen or pelvis
Urinary incontinence symptoms, such as stress, iurgency, or postural

incontinence
Bladder storage symptoms, such as frequency, urgency, or overactive bladder

syndrome
Voiding symptoms, such as hesitancy, slow stream, straining, incomplete

emptying, or position-dependent voiding


Sexual dysfunction symptoms, such as dyspareunia or obstructed intercourse
Anorectal dysfunction, such as fecal incontinence. atal incontinence, fecal
urgency, straining to defecate, constipation, and incomplete evacuation

Women usually present with non-specic symptoms. Specific symptoms may


help to determine the type of prolapse. Aetiological factors should be enquired about.
Abdominal examination should be performed to exclude organomegaly or
abdominopelvic mass.26
Non-specic

symptoms

are

lump.

local

discomfort.

backache.

Bleeding/infection if ulcerated.dyspareunia or apareunia. Rarely.in extremely severe


cystourethrocele. uterovaginal or vault prolapse. renal failure may occur as a result oli
ureteric kinking. Specic symptoms in cystourethrocele are urinary frequency and
urgency. voidingdilliculty, urinary tract infection. Stress incontinence. Specic
symptoms in rectocele are incomplete bowel emptying. Digitation, splinting, passive
anal incontinence.26
In vaginal examination.prolapse may be obvious when examining the patient
in the dorsal position if it protrudes beyond the introitus; ulceration and/or atrophy
may be apparent. Vaginal pelvic examination should be performed and pelvic mass
excluded. The anterior and posterior vaginal walls and cervical descent should be
assessed with the patient straining in the left lateral position. using a Sims speculum.
Combined rectal and vaginal digital examination can be an aid to differentiate
rectocele from enterocele.26
II.l .5.Patophysiology
There are three components that are responsible for supporting the
position of the uterus and vagina:

Ligaments and fascia. by suspension from the pelvic side walls


Levatorani muscles, by constricting and thereby maintaining organ position
Posterior angulation of the vagina, which is enhanced by rises in abdominal
pressure causing closure of the ap valve

Damage to any of these mechanisms will contribute to prolapse. Endopelvic


fascia is derived from the paramesonephric ducts and is histologically distinct from
the fascia investing the pelvic musculature.
It is a continuous sheet that attaches laterally to the arcustendineus fascia pelvis
and levatorani muscles and extends from the symphysis pubis to the ischial spines.
This network of tissue lies immediately beneath the peritoneum. Surrounds the
viscera and lls the space between the peritoneum above and the levators below; in
parts it thickens to form ligaments, eg the uterosacralcardinal complex.
This complex is probably the most important component of the support. The
segment of fascia that supports the bladder and lies between the bladder and vagina is
known as the pubocervical fascia, and that which prevents anterior rectal protrusion
and lies between the rectum and posterior vagina is termed the rectovaginal fascia.26
ll.l.6. Grading
The degree of prolapse is then stiatilied into an ordinal staging system:29

Stage 0: No prolapse
Stage I: Most distal point is greater than 1 cm proximal to the hymen
Stage ll: Most distal point is between l cm proximal to the hymen and 1 cm

distal to the hymen


Stage II: Most distal point is greater than l cm distal to the hymen
Stage IV: Complete eversion of the length of the lower genital tract
In the case of uterovaginal prolapse.the most dependent portion of the

prolapse is the cervix. and careful examination can differentiate uterovaginal descent
from a long cervix. Third degree uterine prolapse is termed procidentia and is
usually accompanied by cystourethrocele and rectocele.26
II.1.7. Imaging
The role of medical imaging in evaluating women with pelvic organ prolapse
is not standardized. Abnormalities identied on history and physical examination or
on other ancillary tests teg. hematuria on urinalysis) may require further evaluation
with abdominal imaging. Empiric upper tract imaging is not mandated. However.an
overall 7.7% prevalence of hydronephrosis has been identied in women undergoing
prolapse surgery. The prevalence was higher in those with worsening prolapse. ln
patients with severe pelvic organ prolapse, a preoperative renal ultrasound may
identify patients who may require additional assessment or changes in management.36

Imaging modalities lune been studied for the diagnosis and quantication of
pelvic organ prolapse. Pelvic ultrasound can be used to diagnosis prolapse and
determine which compartment or organ is responsible for the symptomatic
prolapse. Three-dimensional ultrasound has been used to correlate the degree of
descent with symptoms. Dynamic magnetic resonance imaging has shown correlation
with clinical staging and allows for the measurement of the descent of pelvic organs.37
11.1.8. Differential diagnosis

Anterior wall prolapse: congenital or inclusion dermoid vaginal cyst,

urethral diverticulum.
Uterovaginal prolapse: large uterine polyp.

11.1.9. Treatment
The choice of treatment depends on the patients wishes, level of fitness and
desire to preserve coital function. Prior to specific treatment, attempts should be made
to correct obesity, chronic cough or constipatIon. If the prolapse is ulcerated, a 7-day
course of topical oestrogen should be administered.26
If there is no any symptoms or if the symptoms are mild, it does not need any
special follow-up or treatment beyond having regular checkups. If there were
symptoms, prolapse may be treated with or without surgery.27
If a woman is found to have uterovaginal prolapse on examination but has no
symptoms, then it would be inappropriate to offer any surgical treatment and either
observation or conservative therapy would be best. If symptoms are mild, then pelvic
floor physiotherapy is offered but there are no randomized controlled trials examining
the effectiveness of physiotherapy on prolapse. Silicon rubber- based ring pessaries
are the most popular form of conservative therapy. they are inserted into the vagina in
much the same way as a contraceptive diaphragm and need replacement at annual
intervals. Shelf pessaries are rarely used but may be useful in women who cannot
retain a ring pessary. The use of pessaries can be complicated by vaginal ulceration
and infection. The vagina should therefore be carefully inspected at the time of
replacement. There are a whole range of newer pessaries that are undergoIng
evaluation and these may be more comfortable for the patient.Indications for pessary
treatment are patients wish, as a therapeutic test, childbearing not complete,
medically unfit, during and after pregnancy (awaiting involution), and while awaiting
surgery.26Kegel exercises may be recommended in addition to symptom-related
treatment to help strengthen the pelvic floor. Weight loss can decrease pressure in the
abdomen and help improve overall health. If the symptoms are severe and disrupt
life, and if nonsurgical treatment options have not helped, we may consider surgery.27

The aim of surgical repair is to restore anatomy and function. There are
vaginal and abdominal operations designed to correct prolapse, and choice often
depends on a womans desire to preserve coital function.

26

The following factors

should be considered when deciding whether to have surgery.27

Age
If someone has surgery at a young age, there is a chance that prolapse will
recur and may possibly require additional treatment
Childbearing plans
Ideally, women who plan to have children (or more children) should postpone
surgery until their families are complete to avoid the risk of prolapse

happening again after corrective surgery


Health condition
Any surgical procedure carries some risk, such as infection, bleeding, blood
clots in the legs, and problems related to anesthesia. Surgery may carry more
risks if there is a medical condition, such as diabetes, heart disease, or
breathing problems, or in smoke or obese people.
Surgery also may cause new problems, such as pain during sex, pelvic pain ,
or urinary incontinence.27
In general, there are two types of surgery, the areobliterative surgery
and reconstructive surgery. Obliterative surgery narrows or closes off the
vagina to provide support for prolapsed organs. Sexual intercourse is not
possible after this procedure. Reconstructive surgery reconstructs the pelvic
floor with the goal of restoring the organs to their original position. Some
types of reconstructive surgery are done through an incision in the vagina.
Others are done through an incision in the abdomen or with laparoscopy.27
The types of reconstructive surgey include the following. 27 Fixation or
suspension using your own tissues (uterosacral ligament suspension and
sacrospinous fixation). These procedures are performed through the vagina
and may involve less recovery time than those performed through the
abdomen. A procedure to prevent urinary incontinence may be done at the
same time.
Anterior and posterior colporrhaphy. Because these pro- cedures are
performed through the vagina, recovery time usually is shorter than with
procedures performed through the abdomen.
Sacrocolpopexy and sacrohysteropexy. These abdominal procedures may
result in less pain during sex than procedures performed through the vagina.
Surgery using vaginally placed mesh, mesh placed through the vagina has a

significant risk of complications, including mesh erosion, pain, and infection.


Because of these risks, vaginally placed mesh for pelvic organ prolapse usually is
reserved for women in whom previous surgery has not worked, who have a medical

condition that makes abdominal surgery risky, or whose own tissues are too weak to
repair without mesh.27
Recovery time varies depending on the type of surgery. You usually need to
take a few weeks off from work. For the first few weeks, you should avoid vigorous
exercise, lifting, and straining. You also should avoid sexual intercourse for several
weeks after surgery.27
If urinary symptoms are present, urine microscopy, cystometry and
cystoscopy should be considered. The relationship letween urinary symptoms and
prolapse is complex. Some women with cystourethrocele have concurrent
incontinence; as the prolapse increases in severity, urethral kinking may restore
continence but lead to voiding difficulty. Should renal failure be suspected, serum
urea and creatinine should be evaluated and renal ultrasound performed. For women
with symptoms of obstructed defaecation MR proctography can help diagnose a
rectocele.26
11.1.10. Surgery29
1. Cystourethrocele
Anterior repair (colporrhaphy) is the most commonly performed surgical
procedure but should be avoided if there is concurrent stress incontinence. An anterior
vaginal wall incision is made and the fascial defect allowing the bladder to herniate
through is identified and closed. With the bladder position restored, any redundant
vaginal epithelium is excised and the incision closed.
2. Rectocele
Posterior repair (colporrhaphy) is the most commonly performed procedure. A
posterior vaginal wall incision is made and the fascial defect allowing the rectum to
herniate through is identified and closed. With the rectal position restored, any
redundant vaginal epithelium is excised and the incision closed.
3. Enterocele
The surgical principles are similar to those of anterior and posterior repair, but
the peritoneal sac containing the small bowel should be excised. In addition, the
pouch of Douglas is closed by approximating the peritoneum andJor the uterosacral
ligaments.
4. Uterovaginal prolapse
Uterine preserving sucgery, procedures involving hysterectomy. These
procedures involve removal of the uterus:

Uterine preserving surgery is used largely when a woman still wants to have
further children and therefore the uterus has to be preserved. Occasionally, a woman
wishes to preserve her uterus and then may choose this option:

Hysterosacropexy

This may be performed by an open route or a laparoscopic route and a mesh is


attached to the isthmus of the cervix and the uterus is suspended by attaching the
other part of the mesh to the anterior longitudinal ligament onthe sacrum.

The Manchester repair

This involves accessing the uterus vaginally amputating the cervix and using the
uterosacral cardinal ligament complex to support the uterus. The operation is rarely
used now because of problems with complications to the cervix resulting in either
cervical stenosis or cervical incompetence and a risk of miscarriage.

Le Fort colpocleisis

This operation is used in very frail patients who are unfit for major surgery and are
not sexually active. It involves partial closure of the vagina while preserving the
uterus.

Total mesh procedure using an introducer device

There is a range of mesh using devices that have been designed not only for anterior
and posterior vaginal prolapse but suggest they may be useful in uterovaginal
prolapse and can preserve the uterus. The data for this is scarce.

Vaginal hysterectomy

This is one of the oldest major operations with references dating from the time of
Hypocrates in the fifth century BC. The operation involves making an incision around
the cervix and entering the pentoneal cavity from the vaginal side ligating all the
major blood vessels and delivering the uterus through the vagina and suturing the
vault of the vagina. Obviously, there is lack of support of the vault and to try and
improve support, the standard procedure is to shorten the stretched uterosacral
cardinal ligament complex and then resuture into the vault of the vagina. Some
authors have used variations of this to try and attach the vault even higher in the
vagina with a higher uterosacral ligament fixation. A number of modifications have
been suggested to try and improve the support of the vagina. Some surgeons use
laparoscopically assisted techniques to perform a vaginal hysterectomy if there is
abdominal pathology, but this is not usual for prolapse.

Total abdominal hysterectomy and sacrocolpopexy:

This involves complete removal of the uterus through an abdominal incision,


followed by repair of the vault of the vagina and then attaching a mesh to the vault of
the vagina and suspending it to the anterior longitudinal ligament on the sacrum.
Opening the vagina at the time of inserting a mesh greatly increases the risk of
vaginal erosion and therefore this procedure is not commonly practised.

Subtotal abdominal hysterectomy and sacrocervicopexy

This operation is becoming more popular. It involves either an abdominal or


laparoscopic approach. Most surgeons use the abdominal route. A subtotal
hysterectomy is performed leaving the cervix intact. This means the vagina is not
entered and there is no vaginal scarring. The cervix is then used as an attachment
point for the mesh where there is negligible chance of erosion and the mesh is
suspended to the anterior longitudinal ligament on the sacrum.
If there is concomitant anterior prolapse at the time of vaginal hysterectomy an
anterior repair may be performed. If there is concomitant anterior prolapse at the
time of an abdominal procedure a paravaginal repair can be performed, again
avoiding the need for an incision in the vagina.
5. Vault prolapse
Sacrocolpopexy (Figure 17.8) is similar to sacrohysteropexy but the inverted
vaginal vault is attached to the sacrum using a mesh and the pouch of Douglas is
closed. Sacrospinous ligament fixation is a vaginal procedure in which the vault is
sutured to one or other sacrospinous ligament.
11.1.11. Prevention
Shortening the second stage of delivery and reducing traumatic delivery may
result in fewer women developing a prolapse. The benefits of episiotomy and
hormone replacement therapy at the menopause have not been substantiated.:
11.2. Sacrospinous fixation
11.2.1. Defmition
Sacrocolpopexy is a procedure to correct prolapse of the vaginal vault (top of
the vagina) in women who have had a previous hysterectomy. The operation is
designed to restore the vagina to its normal position and function. A variation of this
surgery called sacrohysteropexy corrects prolapse of the uterus. This operation is
performed in a similar way to sacrocolpopexy.28
11.2.2. Aim

This surgery offers support to the upper vagina minimizing risk of recurrent
prolapse at this site. The advantage of this surgery is that vaginal length is
maintained.29
11.2.3. Indication
Upper vaginal prolapse (uterine or vault prolapse, enteroceles). This
procedure can be used in reconstructive vaginal surgery where increased vaginal
length is required.29
11.2.4. Contraindication
Many of the general contraindications to sacral colpopexy are the same for
any surgical procedure. These may include the following:29

Anemia
Bleeding diathesis or the. need for anticoagulation
Significant cardiac or pulmonary comorbidities
Active infection such as cystitis, bacterial or fungal vaginal infection,

pelvic inflammatory disease, or active sexualfy transmitted disease


Active venous thromboembolism
Uncontrolled hyperglycemia

Other contraindications specific to sacral colpopexy include the following:

Vaginal cancer, cervical cancer, or uterine cancer that is untreated or

cannot be adequately treated due to advanced stage


Fistulas such as vesicovaginal, rectovaginal, vesico-utero, or urethral

fistulas
Previous pelvic prolapse repairs with infected or exposed foreign material
and erosions

Relative contraindications include the following:

Pelvic irradiation
Previous pelvic surgery or prolapse repair, depending on the nature of the
operation and the subsequent pathology, side effects, or complications (the
existence of such may warrant additional diagnostic evaluation and may
require additional surgical intervention or change of approach to prolapse

repair)
Concomitant cystocele, rectocele, or urinary incontinence (the existence of
such pathology may require additional surgery, a vaginal approach, or a
combined approach)

11.2.5. Procedure
11.2.5.1 .Preparation before surgery

Prior to surgical intervention, comorbid conditions should be medically optimized.


Evaluation by an internist or medical specialist may be warranted. Voided urine
should not show evidence of bacteriuria or infection. Medications like aspirin taken
regularly affect the clotting system and may need to be stopped before surgery. Some
surgeons recommend bowel preparation prior to surgery and your doctor will instruct
you if this is required. In most cases you will be asked to avoid food and fluid for 6
houts before surgery.28
Bowel preparation is advised, with the specific regimen at the discretion of the
surgeon. The use of intravaginal estrogen cream before surgery has been
recommended to improve the integrity of the vaginal mucosa, which is often
atrophied in postmenopausal women. A meta-analysis has shown benefit from
intravaginal estrogen for both symptom reduction and measurable urogenital
atrophy.The safety and tolerability has also been well documented.A 6-week
preoperative course of intravaginal estrogen has been proposed to ameliorate vaginal
atrophy.An outcomes benefit from preoperative intravaginal estrogen has not been
clearly established.41
11.2.5.2. Anesthesia
Either general or regional (spinal) anesthesia can be used for abdominal sacral
colpopexy. Adequate abdominal wall relaxation facilitates retractor placement and
allows the bowel to be packed out of the operative field. Decompression of the
stomach with an orogastric or nasogastric tube reduces bowel distention during
surgery. Laparoscopic or robotic-assisted sacral colpopexy requires general
endotracheal anesthesia due to the technical requirements of pneumoperitoneum and
steep Trendelenburg position.
11.2.5.3. Positioning
The patient is placed in modified lithotomy position with both legs secured in
stirrups, allowing for both abdominal and vaginal exposure. All pressure points
should be properly padded to prevent neurapraxia. The patients abdomen as well as
perineum and vaginal mucosa are prepped for sterile draping.
11.2.5 .4.Technique
The key aspect of abdominal sacrocolpopexy is the suspension of the vaginal
apex to the sacral promontory in a manner that recreates the natural anatomic support
provided by the uterosacral and cardinal ligaments.
Steps in an abdominal sacrocolpopexy include the following:
Modified low lithotomy position

Intravenous prophylactic antibiotic (typically cefazolin)


Foley catheter
Pfannenstiel incision a few centimeters cranial to the pubic symphysis
Incision through the rectus fascia and separation of recti abdominis
Entry into peritoneum and exposure of surgical field, with bowel packed away from
the field
Dissection of the bladder away from the anterior vagina along the vesicovaginal
septum; continued posteriorly to separate the vagina from the rectum along the
rectovaginal septum
Placement of an instrument in the vagina
Exposure of retroperitoneal space
Identification of the point for fixation of the graft: the sacral promontory
Selection of graft material and construction of graft
Positioning and fixation of graft in a tension-free manner
Closure of peritoneal reflection over the grail
Surgical concepts of the laparoscopic approach are similar. Additional points
include the following:
Use of 4 or 5 trocar sites
Dissection with laparoscopic monopolar scissors and bipolar cautery
Fixation of mesh with nonabsorbable monofilament sutures and laparoscopic needle
drivers; alternatively, bone anchoring devices are available
Alternative operations for apical (vaginal vault) prolapse repair include the
following:

Sacrospinous ligament fixation


Uterosacral ligament suspension
Iliococcygeus suspension
Steps in vaginal sacrocolpolexy are:26
The procedure can be performed under regional or general anaesthesia.
A routine posterior vaginal incision is made and extended to the top of the

vagina
Using sharp dissection the vagina is freed from the underlying rectovaginal

fascia and rectum until the pelvic floor (puborectalis) muscle is seen.
Using sharp and blunt dissection the sacrospinous ligament running from the
ischial spine to the sacral bone is palpated and identified.

Two sutures are placed through the strong ligament and secured to the top of
the vagina. This results in increased support to the upper vagina. There is no

shortening of the vagina.


Other fascial defects in the vagina are repaired and the vaginal skin is closed

Surgery will be covered with antibiotics to decrease the risk of infection and blood
thinning agents (Clexanself injected for 5 days) will be used to decrease the risk of
clots forming in the postoperative phase.For the first 24 hours postoperatively a
vaginal pack is often inserted into the vagina to decrease the riskof bleeding and a
catheter is used to drain the bladder.
Vaginal sacrospinous ligament fixation has been compared to abdominal
sacral colpopexy in two randomized trials. Benson and colleagues randomized 88
women to receive either vaginal sacrospinous ligament fixation or abdominal
sacrocolpopexy and terminated the study at the interim analysis due to a disparity in
outcome favoring the abdominal approach. Reoperation for cystocele was necessary
in 29% of those in the vaginal group versus 10.5% of those in the abdominal group.
Vaginal vault prolapse recurred in 12% of the vaginal group versus 2.6% of the
abdominal group.38
In a study of 95 women randomized to either approach, Maher et al found a
subjective success rate of 94% in the abdominal group versus 91% in the vaginal
group after a median of 2 years. The objective success rate was 76% in the abdominal
group and 69% in the vaginal group. These differences, however, did not reach
statistical significance.39
In a Cochrane review of 22 randomized controlled trials, abdominal sacral
colpopexy was found to have a lower rate of recurrent vault prolapse and less
dyspareunia. The trend for a lower reoperation rate after abdominal sacral colpopexy
was not statistically significant. There was a longer operating time, longer recovery
period, and higher cost associated with the abdominal approach.40
11.2.5.6. Monitoring and Follow-up
Following surgery, the patient should be discharged with a comprehensive set
of postoperative care instructions. Any strenuous activity or heavy lifting should be
avoided in the immediate postoperative period, usually 6-8 weeks, to allow adequate
time for scar tissue formation. Activities that generate perinea] strain or trauma, such
as bicycle riding, should be prohibited. The patient must refrain from any sexual
intercourse during healing. Additionally, the patient should be instructed to not insert
tampons or applicators into the vagina. A course of antibiotics is often prescribed at
discharge, but level I evidence supporting its use is limited.

11.2.6. Complications
The most commonly reported complications for both open and laparoscopic
techniques include:
Pain(generally or during intercourse) in 2-3%
Exposure of the mesh in the vagina in 2-3%
Damage to bladder, bowel, or ureter in 1-2%
There are also general risks associated with surgery that include wound
infection, urinary tract infection, bleeding requiring a blood transfusion and deep vein
thrombosis (clots) in the legs, chest infection and heart problems. Your surgeon or
anesthetist will discuss any additional risks that may be relevant to you. 28The
sacrospinous fixation is highly effective at con trolling upper vaginal prolapse with a
failure rate of only 5-10%. Buttock pain on the side that the sacrospinous sutures have
been passed occurs in 5-10% women . This can be very painful but usually fully
subsides by 6 weeks.Bleeding requiring transfusion <1%. Damage to the surrounding
organs (bladder, rectum or ureter) occurs rarely and is usually repaired in
surgery.Small risk of clots forming in the legs or lungs after surgery (<1 %). Urinary
tract infection occurs in 1-5%. Painful intercourse can occur in 5% especially if a
posterior vaginal repair is performed. Confidence and comfort during coitus is likely
to be increased as a result of the prolapse being repaired.
Immediate perioperative complications include bowel obstruction, peritonitis,
urine leak from failed intraoperative recognition of a cystotomy, dehiscence, and
infection. Although most of these complications occur rarely, they must be included
in the differential when symptoms occur. Delayed bleeding is a rare complication but
should be entertained in a patient who is hemodinamically unstable.32
Postsurgical complications can be reduced by understanding the risks of the
surgical procedure, including the risks of anesthesia, positioning, surgical technique,
implants, and infection. Neurapraxia can be avoided by proper positioning and
padding of pressure points. In the modified lithotomy position for sacral colpopexy,
femoral nerve injury can occur by hyperextension at the hip and thus should be
avoided. Perineal nerve injury may result from compression against the stirrup if not
properly positioned and padded. Re ducing surgical time will reduce the length of
time the patient is in a position that increases risk for injury. Retractor placement for
exposure of the operative field can lead to nerve injury, most commonly the femoral
nerve as it traverses within the psoas muscle. Venous thromboembolism is another
complication that results from the hemodynamic state established by general
anesthesia, positioning, and surgical manipulation or retractor compression of great

vessels. Postoperative thromboembolic complications were found to be threefold


more likely on multivariate analysis in Medicare beneficiaries undergoing
concomitant prolapse repair with urethral sling surgery compared to urethral sling
surgery alone.Prophylactic measures including placement of sequential compression
devices or antiembolic compression stockings prior to anesthesia induction, early
postoperative ambulation, and prophylactic doses of heparin or low-molecular weight
heparin in those with increased risks factors may help reduce thromboembolic
events.32
Mesh erosion is a late complication of abdominal sacral colpopexy with a
reported rate of 3-7.6%.Lower rates of erosion have been identified with
monofilament polypropylene mesh.Concurrent hysterectomy was associated with
increased erosion rates in one study.Another study did not find associated risk factors
or demonstrate increased erosions with concurrent hysterectomy.Symptoms include
persistent dyspareunia, vaginal discharge, or bleeding.The time from surgery to
erosion varies but has been reported on average to be between 5 and 14 months.33'34
Management of mesh erosion includes transvaginal excision, either partial or
complete graft removal, or laparotomy for complete graft removal. 33Conservative
attempts with mesh trimming, vaginal estrogen cream, and antibiotics often
fail.Suture erosions into the vaginal mucosa, however, have been successfully
remediated through vaginal excision of the suture and cauterization of mucosa,
followed by intravaginal estrogen and oral antibiotic administration.34
The FDA issued a statement that serious complications are not rare with the
use of surgical mesh in transvaginal repair of pelvic organ prolapse, as discussed
further in Equipment. The review found that the most common complication was
erosion of the mesh through the vagina, which can take multiple surgeries to repair
and can be debilitating in some women. Mesh contraction was also reported, which
causes vaginal shortening, tightening, and pain.34

11.2.7. Recovery
After the operation patient will have an IV drip in arm for fluids and pain
relief. They can expect to stay in hospital between 3-6 days. Tliw, iiagimatpay,k,
used, is removed on the first day and the bladder catheter after the first few days or
when your bladder empties appropriately. in the early postoperative period
patient should avoid situations where excessive pressure is placed on the
repair ie lifting, straining, coughing and constipation. Maximal fibrosis around the

repair occurs at 3 months and care needs to be taken during this time. If patient
develop urinary burning, frequency or urgency you should see your local doctor.
Vaginal spotting or discharge is not uncommon in the first 10 but should be reported
to your doctor if heavy or persistent. Patient will have a check up at 6 weeks for a
review and sexual activity can usually be safely resumed at this time. Patient can
return to work at approximately 4-6 weeks depending on the amount of strain that
will be placed on the repair at your work and on how they feel.Avoiding heavy lifting
(> 1 5kg), weight gain and smoking can minimize failure of the procedure in the long
term.28

CHAPTER III
RESEARCH METHOD
III.1. Research Design
This is an observational analytic research, that use bivariate design. The core
of analysis is to compare the symptomatic output between sacrospinous fixation and
non sacrospinous fixation in prolapse patient.While the bivariate correlation describes

the relationship between two variables. In the context of this study, as the independent
variable (independent) is the urinary symptom, defecation symptom, and buttock
pain, while the dependent variable (dependent) is the surgery method. While the
method used is survey method. According to Malhotra (2009), the survey method is
the structure of the questionnaire given to a sample of a population and is designed to
get specific information from the respondents. With data, facts or information
obtained through the surveys, then each study variable can be described and known
the influence of one variable to another variable.
111.2. Reasearch Time and Place
The study will conducted in the Hospital Mohammad Hoesin Palembang in January
2016 by visiting each patient house.
111.3. Population and Sample
According to Sugiyono (2012), the population is a generalization region
consisting of objects or subjects that have certain qualities and characteristics defined
by the researchers to be studied and then drawn conclusions. The population was
hospitalized patients during January to December 2014 in the department of Dr. M.
Hoesin Palembang. This research use a total sampling, so the population that fulfill
the inclusion criteria and exclude the exclusion criteria will be visited to answer the
questionnaire. The inclusion criteria was patient that stayed in South Sumatera, agree
to fill the questionnaire. The exclusion criteria is patient who has been moved to other
address or cannot be contacted.
111.4. Research Variable
111.4.1 . Dependent Variable
The dependent variable is affected or the result of the independent variables.
The dependent variable of this research is the surgery method, with or without
sacrospinous fixation. 111.4.2. Independent Variable The independent variable is the
cause of change or the emergence of the dependent variable. The independent
variable of this study was the urinary, defecation, and buttock pain symptom of the
patient who have done the surgery in Hospital Mohammad Hoesin Palembang.
111.5. Data Collection
The data used for the study came from the primary data by giving
questionnaires to patient who met the inclusion criteria with questions that describe
the urinary, defecation, and buttock pain after sacrospinous fixation and nonsacrospinous fixation. Results of this study in the form of frequency and percentage
(proportion) can be presented in tables and graphs .

111.6. Data Analysis Method


After all the data collected, the data will be examined. If the data were
incomplete and does not comply with the study variable, it was not included in
subsequent analyzes. After that the data will be encoded, summarized, tabulated, and
analyzed using the IBM SPSS program with Chi square test. Analysis of the data in
this study is the bivariate analysis.
111.7. Ethical Principle
Ethical principleswhich will be applied in this study are:
1. Self Determination Researchers give an explanation to potential respondents on the
objectives, benefits, and the research process as well as the rights in research. After
being given an explanation, potential respondents are given the freedom to determine
whether willing or not willing to participate in research without Coercion from any
party. Research subjects must declare its willingness to follow the study by filling
informed consent. To meet the legal aspect, the respondents will be asked to sign a
letter of consent or willingness of respondents without any pressure or coercion from
others.
2. Anonymity and Confidentiality
Researchers ensure the confidentiality of all information given and the data will only
be used for research. Research done no harm to the respondents and respondents'
identities will be kept confidential. Identity data on questionnaires given a code
number that cannot be used to identify the identity of the respondents. Questionnaires
are tilled will be kept by the researcher and not given to the hospital.
3. Beneficence and non Maleficence
Research carried out should consider the benefits and risks that may occur. Research
should not be harmful and should safeguard human welfare. Welfare respondents still
considered to provide assistance to fill in the questionnaire for respondents who have
difficulties and maintain the confidentiality of respondents either in the process of
data collection and research.
4. Justice
In conducting the study, the respondents are treated fairly against both before, during
and after participating in the study, without any discrimination. Everyone is the same
imposed by morals, dignity and human rights.
III. 8. Research Plan

Number

Activity

1.

Submission of

2.

proposals title
Preparation of

3.

proposals
Presentation

4.

of proposals
Improvement

5.

proposal
Data

6.

collection
Data

7.

Processing
Presentation

2015
Month
November

December

2016
Month
January

February

March

of results
Table 1. Research Plan
III.9 Research Budget
Number
Description
1
Stationary
2
Questionnaire
3
Transportation
4
Etc
Total
Table 2. Research Budget

Quantity
1 Packet
100 packet

Price
Rp. 50.000,Rp. 500.000,Rp. 1.500.000,Rp. 500.000,Rp. 2.550.000,-

REFERENCES
1. Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, StecgcrsTheunissen RP, Burger CW, Vierhout ME: The prevalence of pelvic organ
prolapse symptoms and signs and their relation with bladder and bowel
disorders in a general female population. IntUrogynecol J Pelvic Floor
Dysfunct 2009, 20: 1037-45.
2. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL: Epidemiology of
surgically managed pelvic organ prolapse and urinary incontinence.
ObstetGynecol 1997, 89:501-6.
3. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL (1997)
Epidemiology of surgically managed pelvic organ pro- lapse and urinary
incontinence. ObstetGynecol 89:501506

April

4. Fauzi A, Anhar K. kasus prolapses uteri di RumahSakitdr. Mohammad Hoesin


Palembang selama 5 tahun (1993-2003). Naskahlengkap PIT XIV POGI di
Bandung. Bagian/DepartemenObgin F K Unsri/RSMH. Palembang, 2004:119.
5. ProgettoMenopausa Italia Study Group (2000) Risk factors for genital
prolapse in non-hysterectomized women around menopause: results from a
large cross-sectional study in men- opausal clinics in Italy. Eur J
ObstetGynecolReprodBiol 93: 1 3 5140
6. Dallenbach P, KaelinGambirasio I, Dubuisson JB, Boulvain M: Risk
factorsfor pelvic organ prolapse repair after hysterectomy. ObstetGynecol
2007,110:625-32.
7. Sze EH, Karran MM (1997) Transvaginal repair of vault prolapse: a review.
ObstetGynecol 89:466475.
8. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM,
Zyczynski H (2004) Abdominal sacrocolpopexy: a comprehensive review.
ObstetGynecol 104:805823.
9. Carey MP, Slack MC (1994) Transvaginalsacrospinouscolpopexy for vault
and marked uterovaginal prolapse. Br J ObstetGynaecol 101 :536540
10. Sze EH, Karram MM (1997) Transvaginal repair of vault prolapse: a review.
ObstetGynecol 89:466475
11. Kovac SR, Cruikshank SH (1993) Successful pregnancies and vaginal
deliveries after sacrospinousuterosacral fixation in five of nineteen patients.
Am J ObstetGynecol 168:17781786
12. Richardson DA, Scotti RJ, Ostergard DR (1998) Surgical management of
uterine prolapse in young women. J Reprod Med 34(6):388-392
13. Van Brummen HJ, van de PG, Aalders C1, Heintz AP, van der Vaart CH
(2003) Sacrospinoushysteropexy compared to vaginal hysterectomy as
primary surgical treatment for a descensus uteri: effects on urinary symptoms.
IntUrogynecol J Pelvic Floor Dysfunct 142350355
14. Carey MP, Slack MC (1994) Transvaginalsacrospinous col- popexy for vault
and marked uterovaginal prolapse. Br J Ob- stet Gynecol 101:536540

15. Silva-Filho AL, Triginelli SA, Santos-Filho AS, Ca" ndido EB, Traiman P,
Cunha-Melo JR (2004) Sacrospinous fixation for treatment of vault prolapse
and at the time of vaginal hyster- ectomy for marked uterovaginal prolapse. J
Pelvic Med Surg 10:213218
16. Altman D, Granath F, Cnattingius S, Falconer C: Hysterectomy and risk of
stress-urinary-incontinence surgery: nationwide cohort study. Lancet 2007,
370:14949.
17. Mant J, Painter R, Vessey M: Epidemiology of genital prolapse: observations
from the Oxford Family Planning Association Study. Br J ObstetGynaecol
1997, 104:57985.
18. Blandon RE, Bharucha AE, Melton LJ, Schleck CD, Babalola E0, Zinsmeister
AR, Gebhart JB: Incidence of pelvic floor repair after hysterectomy: A
population-based cohort study. Am J ObstetGynecol 2007, 1971664.
19. Nieminen K, Huhtala H, Heinonen PH (2003) Anatomical and functional
assessment and risk factors of recurrent prolapse alter vaginal sacrospinous
fixation. ActaObstetGynecolScand 82:471478
20. Kovac SR, Cruikshank SH (1993) Successful pregnancies and vaginal
deliveries after sacrospinousuterosacral fixation in five of nineteen patients.
Am J ObstetGynecol 168:17781786
21. Rane A, Lim YN, Withey G, Muller R (2004) Magnetic resonance imaging
findings following three different vaginal vault prolapse repair procedures: a
randomised study. Aust NZ J ObstetGynaecol 44:135139
22. Sze EH, Meranus J, Kohli N, Miklos JR, Karram MM (2001) Vaginal
configuration on MRI after abdominal sacrocolpopexy and sacrospinous
ligament suspension. IntUrogynecol J Pelvic Floor Dysfunct 122375379
23. Hefiii MA, ElToukhy TA (2006) Long-term outcome of vaginal
sacrospinouscolpopexy for marked uterovaginal and vault prolapse. Eur J
ObstetGynecolReprodBiol 127:257263
24. Hefni

MA,

E1

Toukhy

TA,

Bhaumik

J,

Katsimanis

(2003)

Sacrospinouscervicocolpopexy with uterine conservation for prolapse in


elderly women: An evolving concept. Am J ObstetGynecol 188:645650

25. Van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH
(2006) Defecatory symptoms during and after the first pregnancy: prevalences
and associated factors. IntUrogynecol J Pelvic Floor Dysfunctl 7(3):224230
26. Shaw R, Luesley D, Monga A (eds). Urogynaecology section. Gynaecology,
4th edn. London: Churchill Livingstone, 2010.
27. December 2013 by the American College of Obstetricians and Gynecologists,
Surgery for Pelvic Organ Prolapse
28. Swift S, Woodman P, O'Boyle A, Kahn M, Valley M, Bland D, et al. Pelvic
Organ Support Study (POSST): the distribution, clinical definition, and
epidemiologic condition of pelvic organ support defects. Am J Obstet
Gynecol. 2005 Mar. 192(3):795-806.
29. International urogynecological association 2011, sacrocolpoplexy, a guide for
women
30. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al.
An

International

Urogynecological

Association

(IUGA)/International

Continence Society (ICS) joint report on the terminology for female pelvic
floor dysfunction. NeurourolUrodyn. 2010. 29(1):420.
31. Swift SE. The distribution of pelvic organ support in a population of female
subjects seen for routine gynecologic health care. Am J Obstet Gynecol. 2000
Aug. 183(2):277-85.
32. Swift S, Woodman P, O'Boyle A, Kahn M, Valley M, Bland D, et al. Pelvic
Organ Support Study (POSST): the distribution, clinical definition, and
epidemiologic condition of pelvic organ support defects. Am J Obstet
Gynecol. 2005 Mar. 192(3):795-806.
33. Anger JT, Weinberg AE, Gore JL, Wang Q, Pashos CL, Leonardi MJ, et al.
Thromboembolic complications of sling surgery for stress urinary
incontinence among female Medicare beneficiaries. Urology. 2009 Dec.
74(6): 1223-6.
34. Begley J S, Kupferman SP, Kuznetsov DD, Kobashi KC, Govier FE,
McGonigle KF, of abdominal sacrocolpopexy mesh erosions. Am J Obstet
Gynecol. 192(6): 1956-62.

35. Kohli N, Walsh PM, Roat TW, Karram MM. Mesh erosion after abdominal
sacrocolpopexy. Obstet Gynecol. 1998 Dec. 92(6):999-1004.
36. Haylen BT, Freeman RM, Swift SE, Cosson M, Davila GW, Deprest J, et al.
An

International

Urogynecological

Association

(IUGA)/International

Continence Society (ICS) joint terminology and classification of the


complications related directly to the insertion of prostheses (meshes, implants,
tapes) and grafts in female pelvic floor surgery. NeurourolUrocb/n. 2011 Jan.
30(1):2-12.
37. Beverly CM, Walters MD, Weber AM, Piedmonte MR, Ballard LA.
Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ
prolapse. Obstet Gynecol. 1997 Jul. 90( 1):37-41.
38. Dietz HP, Lekskulchai 0. Ultrasound assessment of pelvic organ prolapse: the
relationship between prolapse severity and symptoms. Ultrasound Obstet
Gynecol. 2007 Jun. 29(6):688-91.
39. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive
surgery for the treatment of pelvic support defects: a prospective randomized
study with longterm outcome evaluation. Am J Obstet Gynecol. 1996 Dec.
175(6):1418-21; discussion l42l-2.
40. Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ.
Abdominal sacral colpopexy or vaginal sacrospinouscolpopexy for vaginal
vault prolapse: a prospective randomized study. Am J Obstet Gynecol. 2004
Jan. 190(1):20-6.
41. Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical
management of pelvic organ prolapse in women: a short version Cochrane
review. NeurourolUrodyn. 2008. 27(1):3-12.